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CITY CLHJ(
OAtIFORNIAFORM 70,0
FAIR PWirICAL PRACTICES COMMISSION
Please type or print in ink
NAME (LAST)
MAILING ADDRESS STREET
(May use business address)
STATEMENT OF ECONOMIC INT
COVER PAGE
A Public Document
(FIRST)
1) tte--
CITY
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1 . Office, Agency, or Court
Name of Office, Agency, or Court: ,
6170 Lfar� r✓i� ✓ �i
Division, Board, District, if applicable:
Your Position:
If filing for multiple positions, list additional agency(ies)/
position(s): (Attach a separate sheet if necessary.)
Agency:
Position:
2. Jurisdiction of Office (Check at least one box)
❑ State
❑ County of -
�o SAM4 D
City of
❑ Multi- County
❑ Other
3. Type of Statement (Check at least one box)
❑ Assuming Office /Initial Date:
Annual: The period covered is January 1, 2004,
through December 31, 2004.
-or-
0 The period covered is through
December 31, 2004.
❑ Leaving Office Date Left: ��—
(Check one)
O The period covered is January 1, 2004, through the
date of leaving office.
-or-
0 The period covered is through
the date of leaving office.
❑ Candidate
D ale Received
rrrolatr>s,�om
P Fw
nom
(MIDDLE) V I IDNYi(W 1 JMEtER
STATE ZIP CODE OPTIONAL: FAX /.E -MAIL ADDRESS
e,4 9 r 77 ,
4. Schedule Summary
(Check applicable schedules or "No reportable interests.")
�+ During the reporting period, did you'have any reportable
interests to disclose on:
Schedule A -1 ❑ Yes.– schedule attached
investments (Less than 10% Ownership)
Schedule A -2 ❑ Yes – schedule attached
Investments (to% or greater Ownership)
Schedule B ❑ Yes – schedule attached
Real Property
Schedule C ❑ Yes – schedule attached
Income, Loans, & Business Positions (Ineome Other than Gifts and
Travel Payments)
Schedule D (Eliminated – report loans on Schedule C)
Schedule E ❑ Yes - schedule attached
Income – Gifts
Schedule F ❑ Yes – schedule attached
Income – Travel Payments
-or-
r /o reportable interests on any schedule
Total number of pages
completed including this cover page:
5. Verification
I have used all reasonable diligence in preparing this statement.
I have reviewed this statement and to the best of my knowledge
the information contained herein and in any attached schedules
is true and complete.
I certify under penalty of perjury under the laws of the State
of California that the foregoing is true and correct.
Date Signed ' um A o
(month year)
Signature
(File ire unginally signed statement with veer filing aflid.l.)
t• FPPC Form 700 (200412005)
FPPC Toll -Free Helpline: 866 /ASK -FPPC